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Benevolence Request
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Please note that Benevolence Request are not handled in the office, but by the HTBC Board.
Date
*
MM
/
DD
/
YYYY
Full Name
*
Your answer
Address
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
Social Security Number
Your answer
What is Your Request? Please be specific.
*
Your answer
Are you related to an employee, officer, or board member of our organization?
*
Yes
No
If so, please state the person\'s name, position held, and your relationship to him/her.
Your answer
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